03 July 2009

Doing Well in your Cardiothoracic Surgery Rotation

Many times, third-year medical students will have to spend a portion of their required surgical clinical clerkship on Cardiothoracic Surgery. This portion of your surgery clerkship can provide a good informational background for anyone going into medicine, pediatrics or surgery. For the medicine, emergency medicine and anesthesia folks, you get first hand experience with the actions of pressors such as dopamine and dobutamine and other cardio pharmaceuticals in the postop management of these patients. You see the real-time effects of agents like nipride and nitroglycerine because most cardiac surgery patient will have pulmonary artery catheters in place in the immediate post-operative period. For those anticipating entering pediatrics, you will get a chance to see some of the effects of the congenital heart disease entities and how repairs are undertaken. For those entering the surgical specialties, you can develop an understanding of some specialized surgical techniques in addition to becoming familiar with the surgical intensive care unit.
Approaching the Rotation
The first step in any clinical rotation is to have good reference materials so that you understand the language that these surgeons will be using. For cardiothoracic surgery, I strongly recommend the following: Essentials of the Surgical Subspecialties by Lawrence, Cardiac Surgery Secrets by Solotoski or Handbook of Patient Care in Cardiac Surgery by Vlahakes. Any of these books will provide a solid background into the types of pathology that you will encounter in your rotation. The Lawrence book includes good sections on the thoracic elements of this rotation which are not included in the other books. In addition, you need the usual pocket books such as the Pocket Pharmacopeia or Epocrates which may be used to look up dosages of medications and the Maxwell Book which outlines SOAP charting, brief operative notes and discharge summary writing.
The players on any cardiothoracic service are the Cardiothoracic attending surgeon, the resident or fellow surgeon, the intern and you the medical student. You need to understand your role as both a member of the team and as a student of medicine/surgery. This means that in many cases, this busy service will require that you become very proactive in terms of getting the information that you need. You should thoroughly understand the following for every case that you encounter on this service (or any service for that matter):

• The relevant pathology of the underlying disease entity
• The relevant anatomy of the underlying disease entity
• The “gold-standard” of diagnosing the disease entity
• The accepted treatment of the disease entity
• For surgery- the surgical approach and performance of the operative procedure
• For surgery – the postoperative disposition and management of the patient

In the case of a patient that is undergoing a coronary artery bypass graft procedure, you need to understand the indications for the procedure, how the diagnosis of coronary artery disease was obtained (how to read the cath report), where is the disease (in which arteries), the relevant surgical anatomy, how the case is done including the operative approach, how cardiopulmonary bypass works, the effects of the cardiopulmonary bypass pump on the patient and how these effects are managed in the postoperative period, how to read and interpret data from the pulmonary artery catheter, where the grafts for bypass were obtained and how they were utilized and the care of the patient both in the intensive care unit and on the postop ward before discharge home. You should also know why the patient is discharged on certain medications and what you may expect to see and evaluate in the clinic when the patient returns for postoperative care.

Armed with that knowledge, you should make sure that you observe (you probably won’t be actually scrubbing in these cases)the preparation for anesthesia, how the chest is opened and closed, that you see how the grafts are harvested (done by a surgical resident) and how that wound is closed, how the grafts are sewn I place (best to use the camera overhead for this observation rather than try to look over the shoulder of the surgeons, how the pacemaker wires are placed, how the patient is placed on and taken off the cardiopulmonary bypass pump, how the chest tubes are placed in the chest cavity and how blood is evacuated from the chest cavity when the sternal wires are placed. Placement of the sternal wires is also a good opportunity for you to observe an interesting procedure.

After the case, you should accompany the patient to the intensive care unit and you should carefully note and observe the data that is obtained from the pulmonary artery catheter, the arterial line and the 12-lead ECG. You should look at the pre-operative ECG and compare the two. Another good exercise is to note where the grafts were placed and the number of minutes of pump time and any circulatory arrest time. You thoroughly familiarize yourself with the preoperative workup and the postoperative course of every patient that is on your service. Look at things like electrolyte replacement, ventilator weaning, urine output and transfer from the intensive care unit. This is also a good time to learn how to remove chest tubes and arterial lines. You should observe the conversion of the pulmonary artery catheter to a central venous line but leave the rewiring duties to a resident. If you anticipate entering a surgical subspecialty, you might observe these procedures but you should never perform these procedures as a medical student.

In addition to the routine patients, you may get an opportunity to observe some trauma that involved the cardiothoracic service. You may see the repairs of lung lacerations, penetrating cardiac injuries and the relief of cardiac tamponade from a traumatic injury to the chest. It is always interesting to see a patient who is admitted to the emergency department with a stab wound to the chest, knife in placed, rushed off to the operating room where the object is removed and the repair completed with survival of the patient. These are some of the most interesting cases. You may also see how damaged cardiac valves are replaced and how congenital heart defects are repaired. All of these cases are under the practice of a cardiothoracic surgeon.

The thoracic cases may afford you an opportunity to scrub in on the procedures. In the case of the video-assisted thoracic (thorascopic) lung procedures, you will have a good view of lung pathology. You can follow the patient from biopsy (in the case of a tumor) or chest wall abnormalities/problems through the repair. These cases will have interesting anatomy and will have excellent postoperative observations and challenges that will teach you many good skills. You can learn about chest tube management and the physiology of the chest cavity. You will also learn about pain management and the prevention of major postoperative complications as these patients may often be a challenge in terms of pain relief. You may get a chance to observe a thoracentesis or placement of a chest tube.

This rotation can teach you many important skills and hone your ability to understand the critical care of patients. It is an excellent learning opportunity for you. You may not get much hands-op operative experience but you can be invaluable in the post-operative care of these patients.